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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320456
Report Date: 06/13/2025
Date Signed: 06/13/2025 04:19:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2025 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20250606161738
FACILITY NAME:TERRAZA COURT SENIOR LIVINGFACILITY NUMBER:
198320456
ADMINISTRATOR:KAVANAUGH, BRITTANYFACILITY TYPE:
740
ADDRESS:10955 WASHINGTON BLVDTELEPHONE:
(310) 838-7800
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:170CENSUS: 107DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Wellness Director - Michelle BrownTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Staff do not ensure that residents' are being accommodated concerning room and roommate choices
INVESTIGATION FINDINGS:
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13
On 06/13/2025 at around 3:30 PM, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegation listed above. LPA met with Wellness Director Michelle Brown and the purpose of the visit was explained. LPA was granted entry to the facility.






Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 8
Control Number 11-AS-20250606161738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TERRAZA COURT SENIOR LIVING
FACILITY NUMBER: 198320456
VISIT DATE: 06/13/2025
NARRATIVE
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Investigation consisted of the following:

On 06/12/2025, interviews were conducted, resident rooms were toured, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 1 (R1) to Resident 10 (R10) were interviewed] and 8 staff interviews [Staff 1 (S1) to Staff 8 (S8) were interviewed]. The tour consisted of 9 resident rooms. Resident 1 to Resident 5’s (R5) records were gathered which consisted of Admission Agreements, Physicians Report, 30-day notice letter, Care Plan, and other pertinent information. Facility records were gathered which consisted of Resident Roster and Staff Roster. On 6/13/2024, interviews were conducted. Interviews conducted consisted of 5 witness interviews [Witness 1 (W1) to Witness 5 (W5) were interviewed], 2 informal conversations with staff [S8 and Staff 9 (S9)], and 1 attempted interview with Staff 10 (S10).









Continuation to next page.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20250606161738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TERRAZA COURT SENIOR LIVING
FACILITY NUMBER: 198320456
VISIT DATE: 06/13/2025
NARRATIVE
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Investigation revealed the following:

Allegation: “Staff do not ensure that residents' are being accommodated concerning room and roommate choices”, it is being alleged that during the admission process residents agreed to be in a private room without a roommate and now the facility has informed them that they will be having a roommate through a 30-day notice letter. Interviews conducted with R1 to R10 revealed the following: 4 out of 10 residents agreed with the allegation; 6 out of 10 residents do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. Resident 1 to R4 indicated that during their admission process they informed facility staff that they wanted to be in a private room without a roommate and facility staff agreed. Resident 3 indicated that they have not received a 30-day notice indicating that they are eligible for a roommate. Interviews conducted with W1 to W5 revealed the following: 5 out of 5 witnesses indicated that their loved ones (residents) are in a private room. 5 out of 5 witnesses are unaware that residents have a received a 30-day notice indicating that they are eligible for a roommate. Witness 1 is the responsible person and/or Power of Attorney (POA) for R4. Witness 2 and W3 are the responsible person and/or POA for R3. Witness 3, W4, and W5 indicated that they were in the admission agreement meeting with S10 and they informed them that they wanted a private room, no roommates. S10 agreed and informed them that they would have their own private room. Furthermore, on 05/23/2025 Witness 3 (W3) received a phone call from S10 asking for a favor by having a roommate and W3 and R3 declined the offer.
Continuation to next page.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20250606161738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TERRAZA COURT SENIOR LIVING
FACILITY NUMBER: 198320456
VISIT DATE: 06/13/2025
NARRATIVE
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Interviews conducted with S1 to S8 revealed the following: 1 out of 8 staff denied the allegation and 7 out of 8 staff do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. The department attempted to interview S10 but was unsuccessful. Records reviewed of Admission Agreements of R1, R3, and R4 revealed the following: there is no mention of roommates potentially moving into their rooms nor residents agreeing to have a roommate. Staff 10 signed the Admission Agreements for R1, R3, and R4. Witness 2 signature is on R3’s Admission Agreement. Observations of nine resident rooms on 06/12/2025 reveled the following: 7 out 9 residents do not have roommates. Records reviewed of a 30-day notice indicating that they are eligible for a roommate for R1 to R4 do not confirm that residents nor responsible person/POA received the notice. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on observations, interviews, record reviews, and analysis, the preponderance of evidence standard has been met; therefore, the allegations that are determined Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.

An exit interview was conducted, and Wellness Director Michelle Brown was provided with a copy of this report and appeals rights.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20250606161738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TERRAZA COURT SENIOR LIVING
FACILITY NUMBER: 198320456
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/16/2025
Section Cited
CCR
87507(f)
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87507 Admission Agreements
(f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments.

This requirement is not met as evidence by:
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The licensee will recall 30-day notices for R1, R3, and R4.
Licensee will create a plan to stay in compliance with CCR87507(f) to Socorro.Leandro@dss.ca.gov .
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Based on interviews and records review the licensee did not provide the 30-day notice to responsible persons/POAs and R3, the licensee did not follow their admission agreement for R1, R3, and R4 in informing them that they might potentially have a roommate.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/06/2025 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20250606161738

FACILITY NAME:TERRAZA COURT SENIOR LIVINGFACILITY NUMBER:
198320456
ADMINISTRATOR:KAVANAUGH, BRITTANYFACILITY TYPE:
740
ADDRESS:10955 WASHINGTON BLVDTELEPHONE:
(310) 838-7800
CITY:CULVER CITYSTATE: CAZIP CODE:
90232
CAPACITY:170CENSUS: 107DATE:
06/13/2025
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Wellness Director - Michelle BrownTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff altered resident's admission agreement
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/13/2025 at around , Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegation listed above. LPA met with Wellness Director Michelle Brown and the purpose of the visit was explained. LPA was granted entry to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20250606161738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TERRAZA COURT SENIOR LIVING
FACILITY NUMBER: 198320456
VISIT DATE: 06/13/2025
NARRATIVE
1
2
3
4
5
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Investigation consisted of the following:

On 06/12/2025, interviews were conducted, resident rooms were toured, and records were gathered. Interviews conducted consisted of 10 resident interviews [Resident 1 (R1) to Resident 10 (R10) were interviewed] and 8 staff interviews [Staff 1 (S1) to Staff 8 (S8) were interviewed]. The tour consisted of 9 resident rooms. Resident 1 to Resident 5’s (R5) records were gathered which consisted of Admission Agreements, Physicians Report, 30-day notice letter, Care Plan, and other pertinent information. Facility records were gathered which consisted of Resident Roster and Staff Roster. On 6/13/2024, interviews were conducted. Interviews conducted consisted of 5 witness interviews [Witness 1 (W1) to Witness 5 (W5) were interviewed], 2 informal conversations with staff [S8 and Staff 9 (S9)], and 1 attempted interview with Staff 10 (S10).









Continuation to next page.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20250606161738
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: TERRAZA COURT SENIOR LIVING
FACILITY NUMBER: 198320456
VISIT DATE: 06/13/2025
NARRATIVE
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Investigation revealed the following:

Allegation: “Staff altered resident's admission agreement.” Interviews conducted with R1 to R10 revealed the following: 1 out of 10 residents agreed with the allegation and 9 out of 10 residents do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. Interviews conducted with W1 to W5 revealed the following: 5 out of 5 witnesses do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. Interviews conducted with S1 to S8 revealed the following: 1 out of 8 staff denied the allegation and 7 out of 8 staff do not know if the above allegation occurred and/or have not heard residents or staff complaining about the above allegation. Records reviewed of Admission Agreements of R1 to R4 revealed the following: there is no evidence indicating that the admission agreements were altered. Based on the department’s interviews and records reviewed this allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted, and Wellness Director Michelle Brown was provided with a copy of this report.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8